Provider Demographics
NPI:1942212857
Name:GHISELLI, SAMANTHA FAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:FAY
Last Name:GHISELLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S CHERRY ST STE 310
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CO
Mailing Address - Zip Code:80246-1322
Mailing Address - Country:US
Mailing Address - Phone:303-333-7873
Mailing Address - Fax:303-321-7873
Practice Address - Street 1:501 S CHERRY ST STE 310
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CO
Practice Address - Zip Code:80246-1322
Practice Address - Country:US
Practice Address - Phone:303-333-7873
Practice Address - Fax:303-321-7873
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85337207ND0101X, 207ND0900X, 207NS0135X
CO51663207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI62426Medicare UPIN